Ultrasound of Benign Pathology. Reni Butler, M.D. Department of Radiology and Biomedical Imaging Yale School of Medicine

Ultrasound of Benign Pathology Reni Butler, M.D. Department of Radiology and Biomedical Imaging Yale School of Medicine

Ultrasound of Benign Pathology Cyst Intramammary Lymph Node Lipoma Fibroadenolipoma (Hamartoma) Fat Necrosis Fibroadenoma Hematoma Abscess Papilloma

Simple Cyst

Cystic Lesions: Definitions and BI-RADS Assessment Simple Cyst Complicated Cyst Clustered Microcysts Complex Solid and Cystic mass BI-RADS 2 BI-RADS 2 or 3 BI-RADS 3 BI-RADS 4

Complicated Cyst

Complicated Cyst vs. Solid Mass Mobile echoes No internal blood flow Assess margins and orientation Optimize scanning technique Consider context

36 y/o with palpable left breast mass

36 y/o palpable left breast mass At Presentation 4 Months Later

Invasive Ductal Carcinoma

Complicated Cyst Acorn cyst - fluid-fluid level BI-RADS 2

Complicated Cyst Single thin septation BI-RADS 2

Clustered Microcysts Cysts < 2-3 mm with <0.5 mm septations BI-RADS 3

Complex Solid and Cystic Mass Papilloma with ADH

Complex Solid and Cystic Mass Invasive Ductal Carcinoma

Complex Solid and Cystic Mass BI-RADS 4 Differential Diagnosis Papillary lesion Intracystic papilloma/intracystic papillary carcinoma Fibroadenoma/Phyllodes Tumor Necrotic IDC/ILC Abscess Hematoma

Cystic Lesions: Definitions and BI-RADS Assessment Simple Cyst Complicated Cyst Clustered Microcysts Complex Solid and Cystic mass BI-RADS 2 BI-RADS 2 or 3 BI-RADS 3 BI-RADS 4

Ultrasound of Benign Pathology Cyst Intramammary Lymph Node Fibroadenolipoma (Hamartoma) Lipoma Fibroadenoma Hematoma Abscess Fat Necrosis Papilloma

Normal Intramammary Lymph Node Long axis 1 cm Cortical thickness 2 mm Vascularity central

Abnormal Intramammary Lymph Node Metastatic Intramammary Lymph Node Invasive Ductal Carcinoma

54 y/o woman for screening mammogram

Current Prior

Right ML Magnification View

Ultrasound of Benign Pathology Cyst Intramammary Lymph Node Lipoma Correlate with Mammography Fibroadenolipoma (Hamartoma) Fat Necrosis Fibroadenoma Hematoma Abscess Papilloma

Lipoma Homogeneously hyperechoic Circumscribed oval mass with parallel orientation Echogenic capsule CORRELATE WITH MAMMOGRAPHY

Lipoma

Lipoma Invasive Ductal Carcinoma

Fibroadenolipoma Circumscribed mass containing both fat and fibroglandular components Oval mass with parallel orientation Echogenic pseudocapsule CORRELATE WITH MAMMOGRAPHY

Fibroadenolipoma

Fat Necrosis The Great Mimicker Develops 6 months or more after surgery or trauma to the breast May be indistinguishable from malignancy on all modalities, including PE, mammography, US, and MRI Critical to: 1. Obtain history 2. Compare to prior studies 3. Correlate with all available modalities

Fat Necrosis

61 y/o woman with left breast palpable mass & h/o falls

Left MLO Left CC

42 y/o with h/o right mastectomy and DIEP flap reconstruction - palpable mass in medial breast

2D Tomo

76 y/o woman with h/o left lumpectomy new palpable left breast mass

Fat Necrosis Concordant or Discordant?

Ultrasound of Benign Pathology Cyst Intramammary Lymph Node Lipoma Fibroadenolipoma (Hamartoma) Fat Necrosis Fibroadenoma Hematoma Abscess Papilloma

Fibroadenoma Which of these lesions would you biopsy?

32 y/o woman with palpable left breast mass Meets BI-RADS 3 criteria presumed FA, stable on F/U

28 y/o woman 4 weeks post-partum with palpable left breast mass Does this lesion meet BI-RADS 3 criteria? No!

At Presentation 6 month F/U Palpable Mass Left Breast Left Axilla Invasive Ductal Carcinoma, Grade 3, ER/PR-, Her2Metastatic to 5 Axillary LNs

57 y/o with mass seen on routine screening mammogram

Fibroadenoma

74 y/o with new palpable right breast mass and recent benign screening mammogram Calcifying Degenerative Fibroadenoma

Fibroadenoma Fibroadenoma TN IDC Fibroadenoma Fibroadenoma

22 y/o woman with palpable left breast mass 2013 2016 After Full-Term Pregnancy

Ultrasound of Benign Pathology Cyst Intramammary Lymph Node Lipoma Fibroadenolipoma (Hamartoma) Fat Necrosis Fibroadenoma Hematoma Correlate with Clinical History Abscess Papilloma

56 y/o with palpable left breast mass in region of bruising 2 months after fall Diagnosis of hematoma requires: 1. Supporting clinical history 2. Absence of internal vascular flow 3. Follow-up to resolution

65 y/o woman with palpable right breast mass after right breast trauma

At presentation 1 Year Later

33 y/o lactating woman with painful right breast mass

Puerpueral Abscess Successfully Treated with US-guided Aspiration and Oral Antibiotics

Breast Abscess Puerpueral (14-59%) Lactational Primiparous Skin laceration S.aureus Oral antibiotics and aspiration Intralesional antibiotics if large Indwelling catheter if >5 attempts Radiographics 2011;31:1683-1699

Breast Abscess Non-Puerpueral (41-86%) Central (most common) Young women smokers Squamous metaplasia Mixed flora 25% bilateral, 1/3 cutaneous fistulas Oral and intralesional antibiotics Surgery if >7 attempts Lannin 50% of recurring abcesses require surgery 28% recur without surgery, 79% recur in spite of surgery Radiographics 2011;31:1683-1699

Breast Abscess Non-Puerpueral (41-86%) Peripheral Older women with underlying conditions Usually S. aureus Oral antibiotics and aspiration Radiographics 2011;31:1683-1699

Breast Abscess Presentation Clinical context Lactational Young women smokers Older women with underlying conditions Symptoms Pain, warmth, erythema Fever in minority Radiographics 2011;31:1683-1699

Breast Abscess Imaging Ultrasound first-line modality Hypoechoic mass of variable shape & size Thick echogenic periphery with increased vascular flow Mammography R/O inflammatory CA Non-lactational, especially in older women Protracted course Radiographics 2011;31:1683-1699

Breast Abscess Management Oral antibiotics US-guided aspiration 18 g aspiration needle C+S on aspirated fluid Follow-up Repeat US in 1-2 weeks Re-aspirate/ adjust antibiotic coverage if needed Surgical excision if unsuccessful after multiple attempts Radiographics 2011;31:1683-1699

54 y/o woman with h/o abscess treated with antibiotics and US-guided aspiration x 3

Non-Puerpueral Abscess Requiring Multiple USguided Aspirations and Chnages in Oral Antibiotics

59 y/o woman with h/o palpable tender mass treated with antibiotics x 10 days

72 y/o woman with new onset bloody left nipple discharge Differential Diagnosis Intraductal papillary lesion DCIS Inspissated debris

Vacuum Assisted Core Needle Biopsy May Be Helpful Intraductal Papilloma

Benign Lesions Distinction between benign and malignant NOT always clear Identify pathognomonic benign features Be alert for potentially malignant features Remember that no modality exists in a vacuum Correlate with other modalities, i.e., mammography for fat-containing lesions Correlate with clinical history, i.e., hematoma and abscess Further data needed on large/growing fibroadenomas and papilloma management

Thank You!